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Narrative Exposure Therapy

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From Schauer, M., 2015. Narrative Exposure Therapy. In: James D. Wright
(editor-in-chief), International Encyclopedia of the Social & Behavioral Sciences,
2nd edition, Vol 16. Oxford: Elsevier. pp. 198–203.
ISBN: 9780080970868
Copyright © 2015 Elsevier Ltd. unless otherwise stated. All rights reserved.
Elsevier
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Narrative Exposure Therapy

Maggie Schauer, Clinical Psychology, University of Konstanz & vivo international, Konstanz, Germany
Ó 2015 Elsevier Ltd. All rights reserved.

Abstract

Narrative Exposure Therapy (NET; Schauer, Neuner, Elbert 2005/2011) is an evidence-based treatment for trauma spectrum
disorders in adult and child survivors of multiple stressors with complex trauma histories. NET was originally developed to treat
survivors of war, terror, torture, and abuse. Since oral narratives are an integral part of every human culture worldwide, and
imaginal exposure is proven to be a first-line treatment in trauma spectrum disorders, NET ensures healing of trauma symptoms
through these components. The testimony approach that is inherent in this treatment enables the survivors to reclaim their life
stories and also assists societal repair. Based on these principles, it has been shown that individuals from diverse backgrounds
with a high trauma load and broken lifelines, suffering from traumatic stress, significantly benefit from NET. Working through
an individual’s biography facilitates recognition of the interrelated emotional networks of experiences in cases of multiple,
repeated, or continuous trauma and hardship. This helps to build episodic memory and contextual indexing, fosters a sense of
identity, and gives deep personal understanding of schemas and social emotions that have evolved across the lifespan.
Revisiting and processing socially painful situations whilst supported by active, empathic listening allows for a corrective and
healing relationship experience and integration. Subsequently disturbing symptoms significantly decline and the overall health
and immune functions as well as social and occupational functionality increase. In Narrative Exposure work survivors can find
meaning, testify to human rights violations, regain dignity, and satisfy the need for acknowledgment and validation.

Theoretical Underpinnings for Narrative Exposure
Therapy
As humanitarians, we aim at alleviating the plight of war and
complex emergencies, of natural and manmade disasters,
assisting human beings who experience human-/child-rights
violations, abuse, and continuous trauma. When one stressful
experience after another adds to the growing associative
memory of fear and trauma, the feeling of threat becomes
a permanent plight. Given the high prevalence of emotional
neglect, and familial, sexual, and organized violence that is
not limited to geographic regions shaken by war and crisis
but can be found in all countries of the world, low-threshold
trauma treatments are needed to overcome these ‘building
blocks’ of traumatic events and allow remembrance. In search
for straightforward, disseminable approaches that are not
linked to formal education, culture, or age, field-based studies
have shown the efficacy of this short-term, evidence-based
trauma treatment method, Narrative Exposure Therapy
(NET), which can be successfully implemented on a large-
scale level and applied by locally trained lay counselors
(Schauer et al., 2011; Jacob et al., 2014; Neuner et al., 2004b;
Schauer and Schauer, 2010). To heal individuals and commu-
nities it is essential to conduct and evaluate trauma treatments
in real-world settings and to respond to universal human
psychosocial needs (Nickerson et al., 2011; Robjant and
Fazel, 2010).
Typically, the construction of an individual’s reality involves
a dimension of historicization and localization in the
continuum of past, present, and future (Schauer and
Ruf-Leuschner, 2014). Survivors of trauma, however, often
encounter difficulty detailing a biographical account consistent
in both content and sequence (Elbert and Schauer, 2002; Ehlers
and Clark, 2000). In severe and complex cases, entire lifetime
periods can seemingly be lost. Traumatized people fail to
sufficiently connect their impulses, bodily sensations, and
experiences to the contexts of their biography (Schauer et al.,
2005/2011). Individuals who suffer from chronic trauma spec-
trum disorders have typically been exposed to multiple trau-
matic stressors such as assaults and persecution in their
community or repeated incidences of familial violence
including abuse, neglect, and social rejection. Effects are most
devastating when the child had to endure repetitive and pro-
longed stress during development (Elbert and Schauer, 2014;
Ruf and Schauer, 2012; Teicher et al., 2006).
As a consequence of their trauma memory, survivors suffer
from a range of painful symptoms, leading to severe problems
in daily functioning and participation in social life. Symptom
remission and achieving functionality requires traumatic expe-
riences to be oriented in the appropriate context, particularly
the time and place, in the autobiography, i.e., trauma-focused
remembering. Forcing a survivor to simultaneously recall,
rank, and prioritize some traumatic events over others in order
to participate in an ‘exposure exercise’ is often not only techni-
cally impossible but can even hinge on unethical. The process
of having an individual select the ‘worst’ traumatic event
from their trauma history oversimplifies the intricate context
surrounding each event and neglects to address developmental
influences. However, a viable treatment option that circum-
vents such complications and is both efficient and effective
involves the narrating of the entire life story in a manageable
period of time. The steady, step-by-step working through an
individual’s biography facilitates the recognition of interrelated
emotional networks of experiences. The aim of NET is to
complete the survivor’s autobiography by linking hot
(sensory–bodily–emotional) and cold (episodic) memory
traces of events, thus contextualizing the experience of major
traumata. Narrative Exposure builds on the theory of the dual
representation of traumatic memories (Brewin et al., 2010;
Elbert and Schauer, 2002; Schauer et al., 2011).
During a traumatic event, mainly sensory and perceptual
information is stored in memory. The mind and body become

198 International Encyclopedia of the Social & Behavioral Sciences, 2nd edition, Volume 16 http://dx.doi.org/10.1016/B978-0-08-097086-8.21058-1

International Encyclopedia of the Social & Behavioral Sciences, Second Edition, 2015, 198–203
 Author's personal copy
extremely aroused (rapid heartbeat, sweating, trembling) and
brace for actions such as opposing or escaping. Emotional
memories are tied together in a network of sensory, cognitive,
emotional, and physiological elements. The sensory elements,
together with the related cognitive, emotional, and physiological
responses, then form associations in memory related to the
traumatic experiences (hot memory; Metcalfe and Jacobs, 1996;
situationally accessible memory, or sensory perceptual representation,
see Brewin et al., 2010; Schauer et al., 2011). These hot memories
are disconnected from the contextual information that consti-
tutes the cold memory (verbally accessible memory, or contextual repre-
sentation), i.e., the individual cannot remember the event within
their contexts, i.e., where and when they have happened. Envi-
ronmental stimuli and internal cues can easily activate the
trauma structure. Multiple trauma is conceptualized as an exten-
sion of the fear/trauma network through experience of multiple
traumatic events in such a manner that the fear network becomes
increasingly strengthened and enlarged and ultimately can be
triggered by exposure to a wide range of cues contained associ-
ated with the network.
Since the activation of the fear/trauma network serves as
a frightening and painful recollection, many patients learn to
avoid cues that act as reminders of the traumatic event and
are unable to orient the specific fear associated with the events
appropriately in time and space or to clearly structure these
traumatic events in chronological order (Schauer et al.,
2011). Trauma networks connect to response dispositions,
which can either be an alarm response with fight and flight
behavior or dissociative responding (fright, flag, and faint:
e.g., functional sensory de-afferentation, emotional detach-
ment, and numbing while tonic or flaccid immobile). Thus,
dissociative amnesia or ‘shut-down’ can occur, replacing intru-
sions and hyperarousal with dissociation and passive avoid-
ance (for a more detailed understanding of the biology of
surviving and the defense cascade see Schauer and Elbert,
2010). NET is thought to reverse these detrimental conditions
by tying down connections to their exact context.
As adversities and stressors cumulate, the trauma network
expands, ultimately leading to clinically significant trauma-
related suffering. There is a dose–response relationship
(‘building block’) between experiences of traumatic events
and trauma spectrum disorders. All symptoms of traumatic
stress disorders and depression have repeatedly been shown
to correlate in their severity with the cumulative exposure to
traumatic stress (Mollica et al., 1998; Schauer et al., 2003;
Neuner et al., 2004a; Elbert et al., 2009; Schauer E. and
Elbert, 2010). More recently, it has become obvious that
childhood adversity is the other major dimension in
predicting trauma-related mental illness (Catani et al., 2009,
Neuner et al., 2006; Teicher et al., 2003).
We all carry numerous implicit associative neural networks
that have formed in response to emotionally arousing experi-
ences, with many never reaching conscious awareness. Therein,
mutually excitatory mnemonic representations are intercon-
nected with action dispositions (emotions) and behavioral and
physiological responses. Salient discrimination between past
and present, between what are memories and what are current
sensations, is essential. A well-tolerable way to attain this is
working through both the negative and the positive life events
chronologically, furnishing a narration about the entire
International Encyclopedia of the Social & Behavioral Sciences, Second Edition, 2015, 198–203
Narrative Exposure Therapy 199
biography. Reorganizing the memory and embedding the trau-
matic events in one’s stream of life, in their appropriate positions
on an individual’s biographical timeline can achieve acknowledg-
ment and closure of painful experiences. Revisiting positive,
resourceful moments and taking the time to explicitly examine
them one by one helps empower the individual to be able to
look forward to the future (for both see Schauer et al., 2011).
In NET, the individual, with the assistance of the therapist,
constructs a chronological narrative of his or her life story with
a focus on the traumatic experiences. Fragmented reports of the
traumatic experiences will be transformed into a coherent
narrative. Empathic understanding, active listening, congru-
ency, unconditional positive regard, and directive perseverance
are key components of the therapist’s approach for individuals
under continuous trauma conditions, after familial, sexual, and
organized violence, emotional neglect, or social relational
victimization. For traumatic stress experiences the therapist
asks in detail for context, emotions, cognitions, sensory infor-
mation, physiological responses, and probes for respective
observations. The narrator is encouraged to relive these
emotions while actively maintaining their connection to the
‘here and now’: using permanent reminders that the feelings
and physiological responses result from memories, the thera-
pist links the experiences to episodic facts, i.e., time and place.
In this way reprocessing, meaning making, and integration are
facilitated. At the end of treatment the documented autobiog-
raphy may be used for human rights advocacy.
The therapeutic procedure of NET (see Figure 1; for a detailed
account of the structure of NET, see the treatment manual by
Schauer et al., (2011); for a clinicians short description see
Elbert et al., 2015)
l Part 1 (duration: 1–2 sessions, each about 90–120 min):
Structured clinical interview of trauma spectrum disorders
including event checklists followed by a brief psycho-
educational introduction (trauma memory, symptoms,
outline of the treatment rationale and plan, approximate
number of sessions)
l Part 2 is optional (duration: 1 session, 90–120 min): Laying
out the Lifeline as a biographical overview
l Part 3 (duration: about 4–12 sessions, each 90–120 min):
Narrative Exposure as the core procedure of NET, narrating
the life story in several treatment sessions along the chro-
nology of the timeline with an emphasis on high arousing
moments, focusing on the reprocessing of traumatic expe-
riences by inviting ‘imaginal exposure’.
The Character of NET
To heal individuals and communities NET was tested in ecolog-
ically valid, various real-world settings, i.e., in scenarios of
conflict and crisis as well as in typical inpatient and outpatient
clinical settings (Schauer et al., 2004; Onyut et al., 2004, 2005;
Neuner et al., 2004b, 2008a; Bichescu et al., 2007; Maedl et al.,
2010; Neuner et al., 2011; Crombach and Elbert, 2014; Pabst
et al., 2015; Hensel-Dittmann et al., 2011; Robjant and Fazel,
2010). NET was found to be a robust, low-threshold
approach that is not linked to formal education, culture, or
age. Field-based studies have shown the disseminability and
 Author's personal copy
200 Narrative Exposure Therapy

Part 1 Part 2 Part 3

Diagnostics Lifeline Narrative Exposure

Diagnostic Laying out Narration starts at the beginning of life, proceeding along the Closing session: re-
interview including the lifeline lifeline. Traumatic events are confronted and reprocessed reading the entire
event checklists symbolizing (imaginal exposure) until arousal decreases. Notes of key points narration or portraying
+ highly are taken. a final lifeline
Psychoeducation arousing, Between sessions: therapists structures the own transcript, writes
Survivor and all
important the narration down and takes it to the next session.
witnesses (therapist,
events In the following session in sensu exposure is facilitated again
interpreter, co-
through the rereading of the last part of the narration with active
therapist) ritually sign
participation of the survivor. Narration gets corrected and more
the testimony.
details are added.
The procedure is repeated across sessions along the timeline, Document is handed
highlighting important life-events and summarizing others, until a over to the survivor.
Utilization for human
rights work or juridical
purpose is discussed.

Narration

Figure 1 The Narrative Exposure process (Schauer, M., Neuner, F., Elbert T., 2011. Narrative Exposure Therapy: A Short Term Treatment for
Traumatic Stress Disorders, second ed. Hogrefe Publishing, Cambridge, MA.).

efficacy of this short-term, trauma-focused treatment module
that can be successfully built into large-scale service provision
and applied by, e.g., trained counselors, psychologists and
psychiatrists, medics, paramedics, social workers, and teachers
(Schauer, E. 2008; Neuner et al., 2008b; Jacob et al., 2014).
Because narratives are an integral part of every culture, people
from diverse backgrounds with broken lifelines suffering
from stress caused by events such as, e.g., sexual and physical
childhood abuse, forced recruitment or migration, political
violence and torture, life-threatening illnesses, disasters, or
victimization by peers and attachment figures can benefit
from the building of episodic memory and the facilitation of
their testimony. NET has a therapeutic and human rights focus.
Therapeutic elements of NET that have proven effective in trauma
treatment (from Schauer et al., 2005/2011)
1. Active chronological reconstruction of the autobiographical/
episodic memory.
2. Imaginal exposure to the traumatic events (‘hot spots’) and
full activation of the fear memory in order to modify the
emotional network through detailed narration and imagi-
nation of the traumatic events.
3. Meaningful linkage and integration of physiological,
sensory, cognitive, and emotional responses to one’s time,
space, and life context (i.e., comprehension of the original
context of acquisition and the reemergence of the condi-
tioned responses in later life).
4. Cognitive reevaluation of behavior and patterns (i.e., cogni-
tive distortions, automatic thoughts, beliefs, responses), as
well as reinterpretation of the meaning – content through
reprocessing of negative, fearful, and traumatic events –
completion and closure.
5. Revisiting of positive life-experiences to activate resources
and to adjust basic assumptions.
6. Regaining of the survivor’s dignity through satisfaction of
the need for acknowledgment through the explicit human
rights orientation of ‘testifying.’
For full information about the NET procedure, see the treatment
manual:
Schauer, M., Neuner, F., Elbert, T., 2011. Narrative Exposure
Therapy: A Short-Term Treatment For Traumatic Stress
Disorders, second ed. Hogrefe Publishing, Cambridge, MA.
In addition to the English edition, there is currently a Japa-
nese, French, Korean, Slovak, and Italian version of the treat-
ment manual as well as a Dutch interpretation (see references).
Evidence for NET
Adult and child survivors with multiple traumatizing life-events
have been demonstrated to benefit from NET. State-of-the-art
in sensu exposure and the narrative reprocessing of the trauma
memory, the broken lifeline, and ultimately the entire
biography effectively reduces suffering and allows the survivor

International Encyclopedia of the Social & Behavioral Sciences, Second Edition, 2015, 198–203
 Author's personal copy
to foster personal identity (Jongedijk, 2014; Robjant and Fazel,
2010; Dömen et al., 2012). Individuals from diverse
backgrounds with lives torn apart by stressful events like
childhood abuse and neglect, loss of caregivers, adoption,
forced recruitment or migration, political violence and torture,
life-threatening illnesses, severe disasters, and many more
show significantly reduced clinical symptomatology and an
enhanced quality of life and level of occupational and social
functioning (Mørkved et al., 2014; Hermenau et al., 2013;
Dyregrov and Yule, 2006). NET therefore also provides
effective treatment for survivors of organized violence and
severe torture experiences with large effect sizes (Hensel-
Dittmann et al., 2011; Neuner et al., 2010) or complex trauma
survivors, including those with borderline personality
disorders (Pabst et al., 2012a,b, in press). Stenmark et al.
(2013) showed that with NET, refugees as well as asylum
seekers can be successfully treated for post-traumatic stress
disorder (PTSD) and depression in a general psychiatric
health-care system. Most pronounced improvements are
observed at (long-time) follow-up, suggesting that NET elicits
an ongoing change in the dynamics of self-perception and
self-regulation of the client, commencing a healing process
that eventually leads to a sustained improvement in
psychopathological symptoms, physical health, functioning,
and quality of life. NET has effectively been applied in
situations that remain volatile and insecure, like conditions of
continuous trauma, i.e., ongoing real threat, e.g., by war or by
a perpetrator (Neuner et al., 2014). It effectively reduces PTSD
symptoms in the individual whilst bearing witness to the
atrocities endured. Reviews identified NET as an evidence-
based treatment for different groups of survivors of violence
(Robjant and Fazel, 2010; Crumlish and O’Rourke, 2010;
McPherson, 2012; Nickerson et al., 2011). Meanwhile,
a number of studies showing the effectiveness of NET have
been conducted completely independent from the originators
of NET (Zang et al., 2013; Hijazi, 2012; Hijazi et al., 2014;
Gwozdziewycz and Mehl-Madrona, 2013; Ejiri et al., 2012;
D omen et al., 2012) and thus the NET procedure has been
successfully implemented in a variety of countries (e.g., Zech
and Vandenbussche, 2010; Jongedijk, 2012, 2014). NET is
available in special adaptations for offenders (FORNET; Elbert
et al., 2012; Hermenau et al., 2013; Crombach and Elbert,
2014) and for children and adolescents (KIDNET; Schauer
et al., 2005, 2004/2011; Onyut et al., 2005; Catani et al.,
2009; Ruf et al., 2010; Hermenau et al., 2012; Neuner et al.,
2008a; Ruf and Schauer, 2012).
The effectiveness of NET has been demonstrated not only by
measuring the clinical and social symptoms but also in vali-
dating these results by means of markers from neurophysiology
and molecular biology. NET as a successful psychotherapeutic
intervention can reorganize the memory and modify the archi-
tecture of the brain on a macroscopic level (Schauer et al.,
2007, 2006). The success not only showed up in symptom
scores but also in parameters of neuromagnetic activity. During
the 6-month follow-up oscillatory brain activity in the NET
group, but not in the control group, became more similar to
that of healthy controls. Moreover, using magnetic source
imaging of the brain, Adenauer et al. (2011) observed that
NET causes enhanced cortical top-down regulation, which is
associated with the ability to inhibit the fear response.
International Encyclopedia of the Social & Behavioral Sciences, Second Edition, 2015, 198–203
Narrative Exposure Therapy 201
Various somatic diseases, including chronic pain, cancer,
cardiovascular, respiratory, gastrointestinal, and autoimmune
diseases (Boscarino, 2004; Seng et al., 2006; Felitti et al.,
1998), emerge from traumatizing experiences. Altered immune
functions and inflammatory processes are found to be respon-
sible for the poor physical health in individuals with PTSD
(Pace and Heim, 2011). NET was shown to turn health param-
eters (like frequencies of cough, diarrhea, and fever) for the
better even under harsh living conditions (Neuner et al.,
2008b). In the immune system, T-cells are critical for
maintaining balance, regulating the immune response,
and preventing autoimmune diseases. Recently, Morath et al.
(2014) showed a treatment-related increase in the previously
decreased proportion of regulatory T-cells in the NET group
at 1-year follow-up. Moreover, NET is able to reverse in
individuals with PTSD the pathological levels of DNA strand
breaks back to a normal level (Morath et al., 2014b). These
findings may have implications for physical health, including
carcinogenesis.
A decisive strength of NET is its encouragingly low drop-out
rate and, due to its robust nature, the potential for
dissemination, including to counselors in low-income
countries, war, and crisis regions (Schauer and Schauer, 2010;
Catani et al., 2009; Neuner et al., 2008b; Ertl et al., 2011;
Jacob et al., 2014).
See also: Mass Trauma: Psychopathological Effects across the
Life Span; Post-Traumatic Stress Disorder; Post-Traumatic
Stress in Social Work; Torture and its Consequences,
Psychology of.
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